Use of risk assessment instruments to predict violence in forensic psychiatric hospitals: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Violent behaviour by forensic psychiatric inpatients is common. We aimed to systematically review the performance of structured risk assessment tools for violence in these settings. METHODS: The nine most commonly used violence risk assessment instruments used in psychiatric hospitals were examined. A systematic search of five databases (CINAHL, Embase, Global Health, PsycINFO and PubMed) was conducted to identify studies examining the predictive accuracy of these tools in forensic psychiatric inpatient settings. Risk assessment instruments were separated into those designed for imminent (within 24 hours) violence prediction and those designed for longer-term prediction. A range of accuracy measures and descriptive variables were extracted. A quality assessment was performed for each eligible study using the QUADAS-2. Summary performance measures (sensitivity, specificity, positive and negative predictive values, diagnostic odds ratio, and area under the curve value) and HSROC curves were produced. In addition, meta-regression analyses investigated study and sample effects on tool performance. RESULTS: Fifty-two eligible publications were identified, of which 43 provided information on tool accuracy in the form of AUC statistics. These provided data on 78 individual samples, with information on 6,840 patients. Of these, 35 samples (3,306 patients from 19 publications) provided data on all performance measures. The median AUC value for the wider group of 78 samples was higher for imminent tools (AUC 0.83; IQR: 0.71-0.85) compared with longer-term tools (AUC 0.68; IQR: 0.62-0.75). Other performance measures indicated variable accuracy for imminent and longer-term tools. Meta-regression indicated that no study or sample-related characteristics were associated with between-study differences in AUCs. INTERPRETATION: The performance of current tools in predicting risk of violence beyond the first few days is variable, and the selection of which tool to use in clinical practice should consider accuracy estimates. For more imminent violence, however, there is evidence in support of brief scalable assessment tools.

Suicide in prisons: an international study of prevalence and contributory factors.

BACKGROUND: Prison suicide rates, rate ratios, and associations with prison-related factors need clarification and updating. We examined prison suicide rates in countries where reliable information was available, associations with a range of prison-service and health-service related factors, how these rates compared with the general population, and changes over the past decade. METHODS: We collected data for prison suicides in 24 high-income countries in Europe, Australasia, and North America from their prison administrations for 2011-14 to calculate suicide rates and rate ratios compared with the general population. We used meta-regression to test associations with general population suicide rates, incarceration rates, and prison-related factors (overcrowding, ratio of prisoners to prison officers or health-care staff or education staff, daily spend, turnover, and imprisonment duration). We also examined temporal trends. FINDINGS: 3906 prison suicides occurred during 2011-14 in the 24 high-income countries we studied. Where there was breakdown by sex (n=2810), 2607 (93%) were in men and 203 (7%) were in women. Nordic countries had the highest prison suicide rates of more than 100 suicides per 100 000 prisoners apart from Denmark (where it was 91 per 100 000), followed by western Europe where prison suicide rates in France and Belgium were more than 100 per 100 000 prisoners. Australasian and North American countries had rates ranging from 23 to 67 suicides per 100 000 prisoners. Rate ratios, or rates compared with those in the general population of the same sex and similar age, were typically higher than 3 in men and 9 in women. Higher incarceration rates were associated with lower prison suicide rates (b = -0·504, p = 0·014), which was attenuated when adjusting for prison-level variables. There were no associations between rates of prison suicide and general population suicide, any other tested prison-related factors, or differing criteria for defining suicide deaths. Changes in prison suicide rates over the past decade vary widely between countries. INTERPRETATION: Many countries in northern and western Europe have prison suicide rates of more than 100 per 100 000 prisoners per year. Individual-level information about prisoner health is required to understand the substantial variations reported and changes over time. FUNDING: Wellcome Trust and the UK National Institute for Health Research (NIHR).